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Background: Kenya has a maternal mortality ratio of 488 per 100,000 live births. Preventing maternal deaths depends significantly on the presence of a skilled birth attendant at delivery. Kenyan national statistics estimate that the proportion of births attended by a skilled health professional have remained below 50% for over a decade; currently at 44%, according to Kenya’s demographic health survey 2008/09 against the national target of 65%. This study examines the association of mother’s characteristics, access to reproductive health services, and the use of skilled birth attendants in Makueni County, Kenya. Methods: We carried out secondary data analysis of a cross sectional cluster survey that was conducted in August 2012. Interviews were conducted with 1,205 eligible female respondents (15-49 years), who had children less than five years (0-59 months) at the time of the study. Data was analysed using SPSS version 17. Multicollinearity of the independent variables was assessed. Chi-square tests were used and results that were statistically significant with p-values, p < 0.25 were further included into the multivariable logistic regression model. Adjusted odds ratio (AOR) and their 95% confidence intervals were (95%) calculated. P value less than 0.05 were considered significant. Results: Among the mothers who were interviewed, 40.3% (489) were delivered by a skilled birth attendant while 59.7% (723) were delivered by unskilled birth attendants. Mothers with tertiary/university education were more likely to use a skilled birth attendant during delivery, adjusted OR 8.657, 95% CI, (1.445- 51.853) compared to those with no education. A woman whose partner had secondary education was 2.9 times more likely to seek skilled delivery, adjusted odds ratio 2.913, 95% CI, (1.337- 6.348). Attending ANC was equally significant, adjusted OR 11.938, 95% CI, (4.086- 34.88). Living within a distance of 1- 5 kilometers from a facility increased the likelihood of skilled birth attendance, adjusted OR 95% CI, 1.594 (1.071- 2.371). Conclusions: The woman's level of education, her partner's level of education, attending ANC and living within 5kms from a health facility are associated with being assisted by skilled birth attendants. Health education and behaviour change communication strategies can be enhanced to increase demand for skilled delivery.
The study was an analysis of secondary data for cross-sectional baseline survey conducted in August 2012 for an Amref Health Africa intervention project entitled Mama na Mtoto wa Afrika (Mother and Child of Africa). The outcomes of the Mama na Mtoto wa Afrika project focus on increasing the access and utilisation of maternal health services, and increasing the capacity of local health systems to provide quality services. The study was supervised by Amref Health Africa project team, and it aimed at establishing benchmarks for Maternal, Newborn and Child Health Services in Makueni County, Kenya. The sampling frame consisted of the Population and Census Enumeration Areas (EAs) used in the 2009 Population and Housing Census in Kenya conducted by the Kenya National Bureau of Statistics. The primary sampling unit (PSU) referred to as a cluster in this survey was a village. A two-stage sampling design was used. In the first stage, a random sample of villages was selected for each of the 5 district based on probability proportional to their population (PPP). The number of villages selected from each district was determined based on population weights from the 2009 Kenya Population and Housing Census which detailed the number of women and men per household in each locality. In the second stage, a minimum of 20 households were systematically selected from each village, (every 5th household) in order to create a sample size of 1,181 households. Out of the targeted 1,181 women, a total of 1,205 women participated in the survey. The quantitative data collection was done through face to face interviews to eligible female respondents (15-49 years), who had children less than five years ago (0-59 months). If a household had two women who qualified for the study, then one was randomly selected. The household survey was conducted in Makueni County, which is located in the southern end of the Eastern Province in Kenya. The total population of Makueni is 884,527 with 11.8% living in urban areas. [12]. Makueni has a surface area of 8,009 km2 and a density of 110 people per kilometres-km2 [12]. Table 2 outlines the five districts, the total population and the number of households that were sampled. District sampling Data collection took place between August 13th and 23rd, 2012. The survey questionnaire was adopted from the 2008/09 KDHS and was designed to permit the calculation of specific MNCH indicators. The survey tool was pre-tested before data collection began. Trained enumerators were responsible for collecting the data. The survey was in English; however, the enumerators were capable of translating questions into Kamba, the local language, when necessary. The data was first entered into Census and Survey Processing System version 4.0 and then exported to Statistical Package for Social Sciences (SPSS) for further cleaning and analysis. Statistical analysis was based on the specific objectives of: identifying association between the mother’s characteristics and the use of skilled birth attendants during delivery and identifying associations between access to reproductive health services and the use of skilled birth attendants during delivery. The primary outcome of interest is the use of a ‘skilled attendant’ at delivery, which “refers exclusively to people with midwifery skills (for example, doctors, midwives, and nurses) who have been trained to proficiency in the skills necessary to manage normal deliveries and diagnose, manage, or refer obstetric complications” [13]. Within the context of the household survey, traditional birth attendants “are excluded from the category of skilled attendant at delivery” [14]. This is aligned with Kenyan national policies, the World Health Organization and the United Nations Population Fund. The survey asked respondents ‘who assisted with the delivery of (name)?’ Within the analysis, doctors and nurse/midwives were considered as skilled attendants at delivery and traditional birth attendants, relatives, friends or any other individual was classified as unskilled. The mother’s and partner’s levels of education were classified as; no formal education, primary, secondary or higher education. Mother’s religion was categorised as catholic, protestant or other. The employment status was classified as; unemployed (women with no employment), employed and self-employed. The number of births was grouped into 1, 2 and 3 or more. Use of ANC was divided into two; attending ANC sessions and not attending ANC sessions. The number of ANC visits was categorised into one-three visits and four or more ANC visits. The distance to a health facility was divided as 1-5 kilometres and above 6 kilometres. Data analysis was conducted using SPSS version 17.0. Complex Sample Analysis procedure was considered so as to adjust for sample weight, and multi stage sampling. An analysis plan was prepared using strata, cluster and sample weights. Univariate statistics was explored to determine the descriptive statistics. For bivariate analysis, we used chi-square tests to measure the significance of relationships between the outcome variable and the predictor variables. The independent variables were mother’s level of education, partner’s level of education, employment status, number of births in the past five years prior to the study, ANC attendance, as well as distance to a health facility. Multicollinearity of the independent variables was assessed. Results that were statistically significant with p-values, p < 0.25 were included into the multivariable logistic regression model. Adjusted odds ratio (AOR) and their 95% confidence intervals were calculated. A p value less than 0.05 were considered significant. Ethical approval for the secondary data analysis of the cross sectional cluster survey was provided by Amref Health Africa Ethics & Scientific Review Committee (ESRC). The ESRC has been appointed by the Kenya National Council of Science and Technology (NCST) as one of the Institutional Review Boards (IRBs) responsible for the ethical review process in Kenya.
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